1999-2000
Report of the Working Party on the Management of Patients with Head Injuries
1999
2007
2008
2009
2009
?
2010
MAJOR TRAUMA IMPROVEMENT SUMMITimproving treatment and rehabilitation for major trauma patients
May 2010
Paramedic in Control Room
Clinical advice and support Enhanced care teams
Major trauma to major centre 45-minute isochrones
Clinical Advisory Group Recommendations to the
Department of Health
Pre-Hospital Care
The New RulesAll major trauma patients go to a major trauma centre:
– If journey < 45 minutes, directly
– If journey > 45 minutes, they still go to the major trauma centre – indirectly or directly
– If deteriorating, they still go to the major trauma centre – indirectly or directly
Exceptions– If treated immediately at trauma unit and no longer at risk– If immediate trauma unit assessment excludes major trauma
Advisory Group on Pre-Hospital Care 2010
Stoke-on-Trent
Birmingham
Coventry
60 miles
Stoke-on-Trent
Birmingham
Coventry
60 miles
45 minutes by land ambulance
45 minutes by helicopter
ACS 2006
Physiology
Anatomy
Mechanism
Special features
Accuracy of ACS Triage Criteria
Trauma Team and activation
Trauma Team Leader
Emergency Radiology
Emergency Surgery
Clinical Advisory Group Recommendations to the
Department of Health
Acute Care and Surgery
Care should be led by consultants experienced in major trauma
Major trauma is most likely to occur at night-time or at weekends
National Audit Office 2010
Resident Consultant Trauma Team Leaders in Major Trauma Centres
• 24-hour consultant presence in emergency departments treating major trauma patients
• Resident consultant team leader in major trauma centre and ≥ ST4 in trauma unit
• Other consultants available within 30 minutes
Trauma Team Leader
• Often but not necessarily emergency medicine
• Resident status or immediately available
• No conflicting duties – dedicated role
• 1-4 PA per hour versus 1 PA per week
Patient-centred care
Dedicated trauma wards and theatres
Intensive care
Repatriation
Clinical Advisory Group Recommendations to the
Department of Health
Ongoing Care and Reconstruction
Head Injury ‘Scandal’ 1
Time to decompression
Mendelow AD, et al.Extradural haematoma: effect of delayed treatment.
British Medical Journal 1979;1:1240-1241
Acute extradural haematomas have a better outcome if evacuated promptly
A delay of more than 2 hours from clinical deterioration to haematoma evacuation led to significantly worse outcome
59.0% (59*)GOS 5 (good recovery)
7.2%7.7%GOS 2 & 3 (PVS or severe disability)
54.8% (34**)23.1%GOS 4 (moderate disability)
38.1% (57**)10.3% (17*)GOS 1 (death)
6.0 h5.25 hOverall transfer time
0.75 h0.75 hArrival to surgery
2.38 h2.5 hCT to arrival
2.25 h2.0 hDeterioration or injury to CT
4239Number of patients
Acute Subdural Haematoma
Acute Extradural Haematoma
Leach P, et al. Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester
British Journal of Neurosurgery 2007; 21:11-15
* Mendelow 1979 ** Seelig 1981
Number of patients 23
Isolated extradural 9
Mixed extradural and subdural 1
Isolated subdural 7
Intracerebral 4
Mixed subdural and intracerebral 2
Number operated < 4 hours of injury 0
GOS 1 (death) 21.7%
GOS 2 & 3 (PVS or severe disability) 13.0%
GOS 4 (moderate disability) 21.7%
GOS 5 (good recovery) 43.5%
Sergides IG, et al. Is the recommended target of 4 hours from head injury to emergency craniotomy achievable?
British Journal of Neurosurgery 2006;20:301-305
Head Injury ‘Scandal’ 2
Refusing non-operable cases
Old and New Rules
• Closed door to non-operable head injuries
• Gatekeeper protectionism
• Open door to life-threatening intracranial haematomas
• Immediate transfer of responsibility to neurosurgeons
NHS East Midlands
NHS North West
Head Injury ‘Scandal’ 3
Inappropriate repatriation
Appointments
• Director/Clinical Lead in Major Trauma Care• Trauma Nurse Coordinator(s)
To oversee and review early trauma careTo deliver ‘real-time’ clinical governanceTo serve as a bridge between the immediate
care and rehabilitation teams
Early start
Director of Rehabilitation
Coordination
Country-wide review
Clinical Advisory Group Recommendations to the
Department of Health
Rehabilitation
Appointments
• Clinical Lead in Acute Trauma Rehabilitation• Trauma Rehabilitation Coordinator(s)
To coordinate and deliver early trauma rehabilitation
To serve as a single point of contact for patients, family and other support
Journal of Rehabilitation Medicine 2010;42:(in press)
Uncoupling Acute Care from Rehabilitation
• As soon as appropriate after injury
• Converts a ‘push’ system to a ‘pull’ one
Professor Keith Willett (in development)
The costs of major trauma are not fully understood, and there is no national tariff to underpin the commissioning of services
Funding arrangements do not reflect the true costs
National Audit Office 2010
HRG Grid for Major Trauma
Professor Keith Willett (in development)
Definitions and designation
Boundaries based on needs
Responsibility for transfer
TARN mandatory
Performance frameworkClinical Advisory Group
Recommendations to theDepartment of Health
Network Organisation
Primary care trusts should use their commissioning powers to require all acute and foundations trusts with emergency departments that receive trauma patients to submit data to TARN
National Audit Office 2010
By September 2011: TARN Compliance
Incidence of Major Trauma
• 200 per million per year NCEPOD
• 300 per million per year admitted to hospital Intercollegiate Group
Avery B. Nathens; Gregory J. Jurkovich; Ronald V. Maier; et al.Relationship Between Trauma Center Volume and OutcomesJAMA. 2001;285(9):1164-1171
Penetrating Abdominal Injury
Multisystem Blunt Trauma